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A client with a history of Crohn's disease is admitted with a small bowel obstruction. The nurse should give priority to:
- A. Monitoring for dehydration
- B. Administering pain medication
- C. Preparing for surgery
- D. Providing nutritional supplements
Correct Answer: A
Rationale: Small bowel obstruction in Crohn's disease can cause fluid loss through vomiting or sequestration, making monitoring for dehydration the priority to prevent hypovolemia.
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A group of nursing students at a local preschool day care center are going to screen each child's fine and gross motor, language, and social skills. The students will use which one of the most widely used screening tests?
- A. Revised Prescreening Developmental Questionnaire
- B. Goodenough Draw-a-Person Screening Test
- C. Denver Developmental Screening Test
- D. Caldwell Home Inventory
Correct Answer: C
Rationale: The Revised Prescreening Developmental Questionnaire is more age appropriate and offers simplified parent scoring and easier comparison. It is used by parents instead of professionals. The Goodenough Draw-a-Person test is used to assess intellectual development. The Denver Developmental Screening Test is one of the most widely used screening tests. It offers a concise, easy-to-administer, systematic approach to assessing the preschool child. It is widely used because of its reliability and validity. The Caldwell Home Inventory is used to assess the home environment in areas of social, emotional, and cognitive supports.
A client with a history of peptic ulcer disease is admitted with severe abdominal pain. Which medication would the nurse expect to administer?
- A. Ibuprofen (Advil)
- B. Omeprazole (Prilosec)
- C. Aspirin
- D. Acetaminophen (Tylenol)
Correct Answer: B
Rationale: Omeprazole, a proton pump inhibitor, reduces acid production, aiding ulcer healing. Ibuprofen (A) and aspirin (C) worsen ulcers, and acetaminophen (D) addresses pain but not acid.
The nurse is caring for a client who is recovering from a fractured femur. Which diet selection would be best for this client?
- A. Loaded baked potato, fried chicken, and tea
- B. Dressed cheeseburger, French fries, and a Diet Coke
- C. Tuna fish salad on sourdough bread, potato chips, and skim milk
- D. Mandarin orange salad, broiled chicken, and milk
Correct Answer: D
Rationale: A diet for fracture recovery needs protein, calcium, and vitamin C. Mandarin orange salad (vitamin C), broiled chicken (protein), and milk (calcium) (D) are optimal. Other options are less nutrient-dense.
The nurse is caring for a client with a history of a myocardial infarction who is receiving Nitroglycerin. The nurse should monitor the client for:
- A. Hypotension
- B. Tachycardia
- C. Hyperglycemia
- D. Fever
Correct Answer: A
Rationale: Nitroglycerin, a vasodilator, commonly causes hypotension due to decreased preload. Tachycardia is possible but secondary, and hyperglycemia/fever are unrelated.
The nurse caring for a client with closed chest drainage notes that the collection chamber is full.
- A. Add more water to the suction-control chamber.
- B. Remove the drainage using a 60 mL syringe.
- C. Milk the tubing to facilitate drainage.
- D. Prepare a new unit for continuing collection.
Correct Answer: D
Rationale: A full collection chamber requires replacing the chest drainage unit to maintain effective drainage and prevent complications like tension pneumothorax.